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St. Maarten Insurance Association: family doctors are creating ‘free for all’

PHILIPSBURG–St. Maarten Insurance Association (SMIA) Chairman Eric Ellis says the move by family practitioners to ban private insurance cards a year ago and introduce their own, unapproved tariffs is creating a “free for all” in the industry, with some doctors charging one consultation fee and others charging considerably more.

Commenting on the current ban, Ellis said the Price Ordinance (Article 2(1) and (2)) stated that medical practitioners must have the prior approval of the Department of Public Health to increase medical tariffs.

“By introducing their own tariffs, not approved by the Department of Public Health, the WIMA [Windward Islands Medical Association – Ed.] and the SMA have created a “free for all” and a situation where there is no price control. Furthermore, every doctor applies his or her own rate for consultation,” Ellis said.

SMA, he added, does not have the authority to approve an increase (cost-of-living adjustment) in the tariff for medical consultation. Some doctors have applied an increase rate of 25 per cent for consultation (from NAf. 45 to NAf. 56), while some have increased by significantly more.

“When the tariff increase was applied in September 2012 by the WIMA and the SMA, this matter was immediately brought to the attention of the Minister of Public Health [Cornelius de Weever – Ed.].

“The Minister, after several meetings with both the SMIA/WIMA and SMA, informed all parties that a tariff increase would be addressed in the new National Health Insurance. There was no instruction by the Minister to negotiate with WIMA and the SMA,” Ellis noted.

He said the Department of Public Health had invited the SMIA in July and had given it an ordinance that had expired January 2001 that stipulated that parties might negotiate. However, this ordinance (as is the case with the Price Ordinance) clearly states this must be done with the prior approval of the Department of Public Health.

“After this had been brought to the attention of Public Health officials, [Head of Public Health Fenna – Ed.] Arnell subsequently informed the SMIA that we may negotiate. A proposal was sent to the WIMA and SMA on August 12, and a counterproposal was received on Monday, September 23,” said Ellis.

“Concerning the refusal to accept the medical cards, we cannot compel the private doctors to accept the cards. The medical card is a facility created by private insurers so that our clients (patients) may have easy access to medical care. WIMA’s and SMA’s refusal to accept them makes access difficult and impossible in some cases. This matter is of great concern to the St. Maarten Insurance Association.

“It is imperative that this matter be resolved soonest. The St. Maarten Insurance Association will review the latest counteroffer and respond to the WIMA/SMA.”

Another concern he highlighted, which he said had been brought to the attention of public health officials, was the disparity between patients insured with private insurance companies and patients insured with Social and Health Insurance SZV.

“The rate increase will only affect the private insured patients and not SZV patients. At the moment a patient insured with a private insurance company pays NAf. 56 per visit, while a patient insured with SZV pays NAf. 100 per year. We have been creating a huge disparity between patients and this concern should also be addressed,” Ellis said.

Head of Public Health Fenna Arnell said in an invited comment that the difference between private insurance companies and the social and health insurance agency lay primarily in the fact that SZV, which was based on a social principle, had been established by law to execute the Health Insurance Ordinance.

“SZV therefore may not refuse clients based on pre-existing medical conditions, unlike the private insurance agencies. SZV does not have the liberty of risk selection and/or cherry-picking,” Arnell said.

“A person who suffers from chronic illnesses such as high blood pressure, diabetes and/or HIV (pre-existing medical conditions), is refused by the private insurance agencies. Therefore you cannot compare private insurance to SZV or the payment agreement of NAf. 56 per visit to the annual NAf. 100 per client (capitation fee), as you will then be comparing apples with oranges.”

Health Minister Cornelius de Weever said both WIMA and SMIA had been informed from the onset, in a letter dated May 15, 2012, that tariff negotiation was a tool to be used to avoid unfair increases among the uninsured population.

“As the minister, I have the responsibility to maintain a balance within our society. Insurance companies have the obligation to protect the rights of their clients instead of pocketing the difference while increasing premiums annually,” said De Weever.

“Physicians (WIMA and SMA), on the other hand, also have an obligation to ensure that their patients do not become victims due to their inability to negotiate properly with the insurance agencies (SMIA). My main concern is the quality of care being delivered to all those seeking medical care, and that should be the premise of all stakeholders.”